Pinal County Justice Courts, State of Arizona
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APPLICATION FOR DEFERRAL OR WAIVER OF
SERVICE OF PROCESS FEES FOR INJUNCTIONS AGAINST HARASSMENT
AND CONSENT TO ENTRY OF JUDGMENT
Case Number: ___________________________
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Plaintiff(s)
Name / Address / Phone
Defendant(s)
Name / Address / Phone
IMPORTANT
This Application for Deferral of Court Fees and Costs includes a Consent to Entry of Judgment. By signing this Consent, you agree a
judgment may be entered against you for all fees and costs that are deferred but remain unpaid thirty (30) calendar days after entry of
final judgment. At the conclusion of the case you will receive a Notice of Court Fees and Costs Due indicating how much is owed and
what steps you must take to avoid a judgment against you if you are still unable to pay. Additional details about this process are
discussed in the Consent to Entry of Judgment section of this application.
STATE OF ARIZONA
)
ss
COUNTY OF PINAL
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STATEMENTS MADE TO THE COURT UNDER OATH. I swear or affirm that the information in this application is true
and correct. I make this statement under the penalty of prosecution for perjury if it is determined that I did not tell the truth.
I am requesting a deferral or waiver of fee for service of process by a sheriff, marshal, constable or law enforcement agency.
The basis for the request is:
1.
WAIVER: My income and liquid assets are insufficient or barely sufficient to meet the daily essentials of life and
unlikely to change in the foreseeable future.
OR
2.
DEFERRAL:
a.
I receive governmental assistance from the state/federal program(s) checked below:
Temporary Assistance for Needy Families (TANF)
Food Stamps
Supplemental Security Income (SSI)
General Assistance (GA)
for disabilities
Please be prepared to submit proof that you receive governmental assistance. If you are submitting this
application by mail or a third party, please attach a photocopy of that proof.
OR
b.
My income is insufficient or is barely sufficient to meet the daily essentials of life, and includes no allotment
that could be budgeted for the fees and costs that are required to gain access to the court.
OR
c.
I do not have the money to pay the court fee
s and
costs now. I can pay the fees and costs at a later date.
Explain: ________________________________________________________________________________
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11-0118
Revised: 08/08/2008
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